Get Medicare Part B Overpayment Refund Form. Use This Form To Sumbit An Overpayment Or Refund To

Filling out the Medicare Part B Overpayment Refund Form accurately is essential for processing your overpayment requests. This guide provides clear, step-by-step instructions to assist users in completing the form correctly and efficiently.

Follow the steps to fill out the form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your name, the patient's name, and their Medicare number in the designated fields. Include any suffix associated with the Medicare number.
3. Input your address details, including city, state, and zip code, ensuring accuracy for proper processing.
4. Provide the claim number(s) and the service date(s) related to the overpayment. This information is crucial for identifying the specific claim.
5. Fill in the provider number, procedure code, and NPI number to give context about the services rendered.
6. Indicate the overpaid amount clearly in the specified field.
7. Add a contact number where you can be reached for any follow-up regarding this request.
8. For users who have a Corporate Integrity Agreement with OIG, please answer 'Yes' or 'No' as applicable.
9. Confirm the Medicare Secondary Payer reason for overpayment, checking the appropriate box. If applicable, provide detailed information and attach a copy of the primary insurance remittance.
10. Complete the Non-MSP reason for overpayment, checking the relevant box and specifying details for any multiple overpayments.
11. Choose a payment option, if you are enclosing a check, ensure it is addressed to Palmetto GBA or Medicare.
12. Finally, review the completed form for accuracy. Once confirmed, print, sign, and save your changes before submitting the form to the appropriate address listed for your region.

Take the next step and complete your Medicare Part B Overpayment Refund Form online today.